Opportunity to Integrate the American Medical Association's Inclusive Language Guidance

Inclusive language is a cornerstone for inclusive, just, and equitable health care. While the American Medical Association released inclusive language guidance in 2021, it was unclear the extent to which physician practice organizations and their affiliated journals have adopted and promoted inclusive language. In our analysis, we found a lack of inclusive language resources across many physician practice organizations and their affiliated journals. Moreover, when guidance was provided by such entities, it was sometimes limited or not reflective of the American Medical Association recommendations. As such, many practice organizations and their journals have the opportunity to promote inclusive language.

Inclusive Language: Importance and Impact Inclusive language use is a way physicians may embody the American Medical Association (AMA) ethical principles of beneficence and nonmaleficence, 1 as referring to people, their identities, bodies, and their care with dignity and respect is central to promoting their wellbeing and avoiding harming or injuring individuals.4][5] Inclusive language goes beyond simple choice of words, as words build meaning within narratives and narratives can alter or reinforce beliefs and behaviors that compound inequities.Consequently, inclusive language is a cornerstone of delivering structurally competent 6 and responsive care.
Multiple publications encourage the use of person-first language when referring to people with health conditions and lived experiences.For example, instead of referring to someone as ''an opioid addict,'' a person-first approach would use ''a person living with opioid-use disorder'' instead. 7,8At times, inclusive language may also include identity-first language (e.g., ''autistic people''), as members of communities have pride in and have reclaimed and destigmatized parts of their identities. 9,10nclusive language includes the recognition of assigned sex and gender as distinct aspects of identity, that gender identity can be expansive and dynamic, and the agency each person has to self-identify their gender.For example, phrases such as ''he/she'' to refer to an unknown or unidentified person are noninclusive of people who use other pronouns.In contrast, ''they'' is an inclusive choice when referring to an unknown or unidentified person, and is grammatically sound. 11Inclusive language evolves over time, and hence, ensuring up-to-date knowledge is an important opportunity for physicians to ensure equitable health care practices.
Over the past few years, inclusive language guidelines have been released by major practice organizations and government entities such as the AMA, 12 the American Psychological Association, 13 and the Centers for Disease Control and Prevention. 14While these published guidelines have nuanced differences in specific terms, all describe recommendations regarding the use of person-first language and identity-first language (although consensus is not necessarily reached with all terms).In addition, these guidelines emphasize the importance of intentionality and awareness of how language shapes perception.For example, the AMA Advancing Health Equity: A Guide to Language, Narrative, and Concepts in 2021 was created in collaboration with the Association of American Medical Colleges, 12 and delineates differences between the intent, impact, and the role of language in systemic health injustices in addition to specific language recommendations. 12mportant goals of the AMA Guide include stimulating critical thinking about language, narrative, and concepts to work toward healthcare justice and health equity. 12While the AMA Guide was released more than 2 years ago, it is unclear the extent to which physician practice organizations and affiliated journals have adopted the recommendations of the AMA Guide.Therefore, the goal of this analysis was to evaluate the extent to which inclusive language recommen-dations in particular-or diversity, equity, inclusion, and justice (DEIJ) resources in general-are publicly accessible and published on physician practice organizations and their affiliated journal websites.

Evaluating Accessible Information in Practice
Organizations' and Journals' Websites Practice organizations were identified through a search of the American Board of Medical Specialties (ABMS) website (www.abms.org).A total of 26 U.S. medical specialties and the AMA were identified (note: Psychiatry and Neurology are organized under one ABMS Board, but were disaggregated for this study), and their corresponding professional organization website was identified using the Google Search Engine (Mountain View, CA).
We searched practice organization and journal websites through December 16, 2023, using embedded search functions embedded within each practice organization's website for the following phrases: ''inclusive language,'' ''inclusive terminology,'' ''diversity, equity, inclusion, justice (DEIJ) resources,'' ''DEI resources,'' ''diversity resources,'' and ''diversity.''If the embedded search function was not available or did not produce results, we used Google to search for these terms with the practice organization's name added to the search phrase.If there were multiple resources for a particular practice organization, results were prioritized as follows: (1) inclusive language guidance and resources, followed by (2) DEIJ resources in general; then if neither (1) nor (2) was identified, (3) public statements or policies regarding DEIJ commitment were identified.Published articles identified in the organization website searches were not extracted, as the goal was to identify public-facing, accessible guidance produced by the organizations.
Identified resources for each practice organization were searched as noted above, and data were extracted by one of the team members (K.B.H. and Y.W.); the data were then independently verified by at least one other team member (K.B.H., Y.W., and M.A.L.).Search information is collated into Table 1 in which each organization's website was identified as having accessible inclusive language guidance (Yes, No-but includes DEIJ resources and/or statement, and None).
Both pregnant women'' and ''pregnant people'' are acceptable terms.Avoid substituting ''pregnant women'' with phrases such as ''birthing people'' or ''language.''Similar to organization's websites, each journal's author's instructions were identified as having inclusive language guidance (Yes or No).If yes, information regarding the specific inclusive language guidance was included in the summary table (Table 1).Aside from the AMA, five practice organizations published explicit inclusive language guidance, although this guidance was not always consistent with the AMA (or APA) Guide.Half of the practice organizations (n = 13) had listed resources and/or links to DEIJ resources that organization members and members of the public could access.Five practice organizations did not contain easily accessible DEIJ resources but included a public statement regarding the organization's commitment to DEIJ.Two practice organizations lacked accessible inclusive language guidance or DEIJ-related resources or statements.Of organization websites that contained accessible inclusive language guidance, the guidance varied, with some including limited scope (e.g., refer only to assigned sex and gender) or including information that was inconsistent with the AMA Guide.
For affiliated journal websites, 15 (57%) included explicit inclusive language guidance, however, the depth and scope of the guidance varied.For example, some journals included only recommendations regarding assigned sex and gender terminology, while others included more recommendations regarding reporting and terminology for assigned sex, gender, race, ethnicity, and disability.Four organization-journal combinations (15%) had accessible inclusive language guidance across both their organization and journal websites.
Where to Go from Here Lack of accessible and consistent inclusive language guidance and existing discrepancies between practice organizations and journal recommendations provide an opportunity for improvement to support and recommend inclusive language in articles.Given that the AMA Manual of Style updates guidance regularly (e.g., language regarding race and ethnicity reporting), with plans for ongoing updates, 15 it will be important for practice organizations and journals to implement responsive inclusive language recommendations and DEIJ resources.Practice organizations are an important potential source of institutional and structural inequities, or they can serve as a proactive force to decrease inequities and bias at an institutional level.
While some practice organizations may encourage members to advocate for inclusive language changes (e.g., medical record field changes and updated electronic medical records), having accessible inclusive language guidance published and championed by individual practice organizations may accelerate ongoing institutional improvements and advocacy.Moreover, the enhanced accessibility of such inclusive language guidance will more consistently communicate the importance of integrating inclusive language throughout physicians' practices and work environments.
Many approaches could enhance organizational inclusive language implementation.Such efforts can increase the inclusivity and more accurately describe health and health care within a structurally responsive manner. 6Practice organizations could collectively agree to adopt, disseminate, and promote the AMA Guide in their organization-specific guidance.Accrediting bodies (such as the Joint Commission, Association of American Medical Colleges) and publishers could bolster inclusive language guidance and consistently refer to the AMA Guide.Increased transparency of inclusive language development and inclusion of diverse representation in the process are critical to elevate the voices and lived experiences of diverse individuals and ensure contributors are provided public recognition.Lastly, the AMA could ensure that inclusive language recommendations in its Manual of Style and the Guide are sufficiently flexible with regular updates to reflect the evolution of inclusive language.
Limitations to the Present Evaluation Our sampling included current ABMS specialties, however, this does not encompass all medical specialties.Our methodology may have missed additional organizations and subspecialty organizations within the specialties queried with their own inclusive language guidelines and journal recommendations.In addition, statements were located by searching public facing websites and journal submission portals, which may have missed nonpublicly available guidelines.

Table 1 .
Practice Organizations, Flagship Journals, and Identified Guidance in Inclusive Language are more appropriate and (self-) explanatory such as ''primary,'' ''secondary,'' ''blocklist,'' and ''allowlist.''These guidelines are meant as a point of reference to help identify appropriate language but are by no means exhaustive or definitive.''''Inclusive language acknowledges diversity, conveys respect to all people, is sensitive to differences, and promotes equal opportunities.Content should make no assumptions about the beliefs or commitments of any reader; contain nothing which might imply that one individual is superior to another on the grounds of age, gender, race, ethnicity, culture, sexual orientation, disability or health condition; and use inclusive language throughout.Authors

Table 1 .
(Continued) should ensure that writing is free from bias, stereotypes, slang, reference to dominant culture and/or cultural assumptions.Seek gender neutrality by using plural nouns (''clinicians, patients/clients'') as default/wherever possible to avoid using ''he, she,'' or ''he/she.''Avoidthe use of descriptors that refer to personal attributes such as age, gender, race, ethnicity, culture, sexual orientation, disability or health condition unless they are relevant and valid.Refer to the current AMA style guide on race and ethnicity for a complete discussion and examples.These guidelines are meant as a point of reference to help identify appropriate language but are by no means exhaustive or definitive.Please see the full AMA Manual of Style for more information.''

Table 1 .
(Continued)If so, this is inappropriate.Is sex being used as a proxy for gender or vice versa?In most cases this would be considered inappropriate.Are white populations or European ancestry groups being used as reference categories in analysis?If so, is there a scientific justification for this comparison?In studies of genetic contributions to health disparities, are social determinants of health, environmental exposures and other likely relevant variables included?If not, is the possible role of these nongenetic factors discussed as a limitation?Is the study providing findings from underrepresented populations?If not, is a rationale provided, and discussion of the limitations of the generalizability of If not, is a rationale provided, and discussion of the limitations of the generalizability of the study?Inclusive language acknowledges diversity, conveys respect to all people, is sensitive to differences, and promotes equal opportunities.Content should make no assumptions about the beliefs or commitments of any reader; contain nothing which might imply that one individual is superior to another on the grounds of age, gender, race, ethnicity, culture, sexual orientation, disability or health condition; and use inclusive language throughout.Authors should ensure that writing is free from bias, stereotypes, slang, reference to dominant culture and/or cultural assumptions.We advise to seek gender neutrality by using plural nouns (''clinicians, patients/clients'') as default/wherever possible to avoid using ''he, she,'' or ''he/she.''We recommend avoiding the use of descriptors that refer to personal attributes such as age, gender, race, ethnicity, culture, sexual orientation, disability or health condition unless they are relevant and valid.These guidelines are meant as a point of reference to help identify appropriate language but are by no means exhaustive or definitive.Race, Ethnicity, and Genetic Ancestry For race, ethnicity, and genetic ancestry terms please refer to ''Updated Guidance on the Reporting of Race and Ethnicity in Medical and Science Journals published in JAMA'' and follow the copy editing guidelines in the AMA Style guide.''

Table 1 .
(Continued)Articles that report race and/or ethnicity should use the specific terms used in data collection or in the original study referenced.The terms should be accurate, understandable to study participants, and consistent with participants' self-understanding.

Table 1 .
''people with uteruses.''Neutralterms,suchas ''pregnant patients'' and ''pregnant people'' are inclusive alternatives.Authors of research studies should use the specific terms used in data collection or in the original study referenced.''(Continued)Statewhatdefinitions of sex and/or gender they are applying to enhance the precision, rigor and reproducibility of their research and to avoid ambiguity or conflation of terms and the constructs to which they refer (see Definitions section below).Authors can refer to the Sex and Gender Equity in Research (SAGER) guidelines and the SAGER guidelines checklist.These offer systematic approaches to the use and editorial review of sex and gender information in study design, data analysis, outcome reporting and research interpretationhowever, please note there is no single, universally agreed-upon set of guidelines for defining sex and gender.DefinitionsSex generally refers to a set of biological attributes that are associated with physical and physiological features (e.g., chromosomal genotype, hormonal levels, internal and external anatomy).A binary sex categorization (male/female) is usually designated at birth (''sex assigned at birth''), most often based solely on the visible external anatomy of a newborn.Gender generally refers to socially constructed roles, behaviors, and identities of women, men and gender-diverse people that occur in a historical and cultural context and may vary across societies and over time.Gender influences how people view themselves and each other, how they behave and interact and how power is distributed in society.Sex and gender are often incorrectly portrayed as binary (female/male or woman/man) and unchanging whereas these constructs actually exist along a spectrum and include additional sex categorizations and gender identities such as people who are intersex/have differences of sex development or identify as non-binary.Moreover, the terms ''sex'' and ''gender'' can be ambiguous-thus it is important for authors to define the manner in which they are used.In addition to this definition guidance and the SAGER guidelines, the resources on this page offer further insight around sex and gender in research studies.''All primary research reports are required to include information on the age, sex, gender identity, race, and ethnicity of the study subjects.The Methods section should include an explanation of how each participant characteristic was identified (e.g., self-report, investigator observed) and the source of the classifications used (e.g., U.S. Census data, PhenX toolkit).If the study design precluded the acquisition of any of these participant characteristics, an explanation should be provided.Studies that include predominantly White participants should acknowledge this limitation and note that findings may not generalize to non-White participants.Race and ethnicity should be treated as social constructs and when indicated, should be discussed in relation to the social, environmental, and economic factors in the study population.Description of subject characteristics should